Jump to content


Photo

WBC & Dosage Strength


  • Please log in to reply
36 replies to this topic

#1 Melanie

Melanie

    Advanced Member

  • Members
  • PipPipPip
  • 219 posts
  • LocationArizona

Posted 22 April 2012 - 06:31 PM

Was wondering if anyone knows if there has been any studies on WBC and strength of TKI dosage.  Thought being the higher the WBC count = higher dosage and lower WBC = lower dosage. I'm thinking if someone has chronic low WBC, say below 3.5, would it make sense that maybe a lower dose of TKI drug would be as effective instead of trying to get to "normal" doasage which typically causes ANC to be dangerously low and have to stop or lower the drug dosage anyway?  I was told that with the low WBC, the CML was probably not as active anyway and not producing new cml cells. Does that sound right?


Dx - 05/2011; PCR: 15.04; Fish: 87% Slow responder due to pancytopenia. Current - Bosulif - Nov: 2012, Mar 2016 lowered to 300 mg. 07/16 back to 400 mg. Clinical trial drug, Promacta, Feb 2013, for low Platelets.
CyCR - Aug 2014, Positive for 1 chromosome Sep 2015. PCR: 12.77 in Oct, 2012 to 0.04 (MDA) in Mar, 2016. 4/2016 - 0.126 (Local lab (IS); 05/2016 - 0.195 (local); 6/2016 - 0.07 (MDA); 7/2016 - 0.03 (local) 9/13/2016 - 0.16 (MDA); 9/26/2016 - 0.31 (MDA); 11/2016 - 0.012 (local); 01/2017 - 0.24 (MDA); 04/2017 - 0.09 (MDA); Cytogenetics show der(1:7)(q10;p10)7 chromosome mutation. Repeat of Sep 2015. PCR - 6/2017- 0.035 (local); 10/2017- 0.02 (MDA)

#2 Trey

Trey

    Advanced Member

  • PS Beta Group
  • PipPipPip
  • 1,705 posts
  • LocationSan Antonio, Texas

Posted 22 April 2012 - 07:11 PM

The WBC at diagnosis does not affect Gleevec initial dosage, although not your main question.  After the WBC has returned to normal or below, then dosage is normally only altered if the person cannot maintain a high enough neutrophil count (ANC) after taking a couple breaks to attempt to reset the issue.  If the ANC and overall WBC remains very low, then dosage may be lowered, but it would usually be better to switch drugs. 

Your theory about the low WBC meaning low leukemic cell activity is inaccurate.  A person can have very low WBC, but if nearly all of those WBCs are leukemic, that is not a good thing.  The key is that BMB cytogenetics, FISH, and PCR will tell you how well you are progressing in fighting the leukemia.  The only time the WBC can show anti-leukemic activity is the initial response down to normal WBC, which can show that the drug appears to be working.  But that is only at the "worker bee" WBC level, and the real test is when the drug tries to kill off the higher level leukemic WBCs.  So to reiterate, the low WBC does NOT mean that the CML is "not as active". 



#3 Lori's okay

Lori's okay

    Member

  • Members
  • PipPip
  • 21 posts
  • LocationWashington DC area

Posted 22 April 2012 - 09:00 PM

Trey,

Is there a link I could go to to better understand the "higher level" terminology?  I've seen you talk about this several times and would love to understand it better.


DX 09-2011 PCR 8.08 not IS WBC 17 , Began Tasigna 600mg  

in 2012 Tasigna 450mg/day ,in 2013-2017 Tasigna 300mg/day

DATE/PCR

09-11/ 8.08 not IS

03-12/ 0.054 not IS

06-12/ 0.035 not IS

09-12/ PCRU, 01-13/ PCRU

4-13/ 0.042 IS

7-13/ 0.014 IS

11-13/ PCRU, 04-14/ PCRU

8-14/ 0.006 IS

PCRU: 12-14/ 05-15/ 10-15/ 02-16/ 

09-16/ 02-17/ 09-17/ 

10-17 tapered off 

11-3-17 Stopped Tasigna

1-15-18 still PCRU

 


#4 Trey

Trey

    Advanced Member

  • PS Beta Group
  • PipPipPip
  • 1,705 posts
  • LocationSan Antonio, Texas

Posted 22 April 2012 - 09:45 PM

An exceptional write-up by one of the world's foremost authorities:

http://community.lls.org/docs/DOC-1272



#5 Melanie

Melanie

    Advanced Member

  • Members
  • PipPipPip
  • 219 posts
  • LocationArizona

Posted 22 April 2012 - 09:50 PM

Trey, thank you for your response. It appears I've been mislead about low WBC meaning low CML activity, which lead me to thinking that with chronic low WBC and low ANC, caused by "normal" dosage of the TKI drugs, that a logical and better solution would be a lower dose. Thinking that continuing on some dosage of drug is better than no drug for long periods of time. You know...some offense is better than no offense. I've been on all 3 of the TKI drugs with the same effect at "normal" dosage causing low WBC & low ANC. Each time, I've had to stop the drugs for weeks, even months for my counts to get close to normal. I start out slow, but each time I get to 3/4 to full dose, then my WBC sink to 1.6 and ANC to .02 again. I thought that with such low counts, then maybe all I ever really need is 1/2 dose to get same effectiveness as full dosage for normal counts. What are the higher level leukemic WBCs. I'm assuming that only full dosage of the drug are effective in killing at that level. Thanks, Melanie


Dx - 05/2011; PCR: 15.04; Fish: 87% Slow responder due to pancytopenia. Current - Bosulif - Nov: 2012, Mar 2016 lowered to 300 mg. 07/16 back to 400 mg. Clinical trial drug, Promacta, Feb 2013, for low Platelets.
CyCR - Aug 2014, Positive for 1 chromosome Sep 2015. PCR: 12.77 in Oct, 2012 to 0.04 (MDA) in Mar, 2016. 4/2016 - 0.126 (Local lab (IS); 05/2016 - 0.195 (local); 6/2016 - 0.07 (MDA); 7/2016 - 0.03 (local) 9/13/2016 - 0.16 (MDA); 9/26/2016 - 0.31 (MDA); 11/2016 - 0.012 (local); 01/2017 - 0.24 (MDA); 04/2017 - 0.09 (MDA); Cytogenetics show der(1:7)(q10;p10)7 chromosome mutation. Repeat of Sep 2015. PCR - 6/2017- 0.035 (local); 10/2017- 0.02 (MDA)

#6 PhilB

PhilB

    Advanced Member

  • Members
  • PipPipPip
  • 130 posts

Posted 23 April 2012 - 05:40 AM

Looks like someone needs a bigger hat again...



#7 Trey

Trey

    Advanced Member

  • PS Beta Group
  • PipPipPip
  • 1,705 posts
  • LocationSan Antonio, Texas

Posted 23 April 2012 - 09:17 AM

Melanie,

A lower dosage that you can stay on is better than a higher dosage that you cannot stay on.  Given that you have tried all 3 drugs, if I had to take a low dosage (and had not achieved MMR) it would be Sprycel. 



#8 scuba

scuba

    Advanced Member

  • Members
  • PipPipPip
  • 1,044 posts
  • LocationHouston, Texas

Posted 23 April 2012 - 09:49 AM

Melanie,

I was in your shoes with myelosuppression at normal dose for Gleevec and severe myelosuppression with near normal dose for Sprycel. I had to stop TKI therapy for weeks and even months. After my counts recovered (not normal, but higher) - I was re-started on Sprycel at 20mg. This is a very low dose. Since that time, I have achieved MMR in seven months. You should consider low dose Sprycel and then work up from there if needed.

I am very puzzled that the CML specialists, when faced with myelosuppression in their patients, keep trying the high dose's with drug interuption rather than go the other way and see if response stabilizes at a low dose and then work up.

In my case, once started at 20mg. - it seems to work, so I have stayed at this dose. One big benefit is no side affects that I can feel.

So as Trey wrote, 'A lower dose that you can stay on beats a higher dose that you can't stay on'. The only caveat is that the lower dose must be able to provide downward response of the CML. If it does that, albeit a bit slower, you're going to be fine.


Diagnosed 11 May 2011 (100% FiSH, 155% PCR)

with b2a2 BCR-ABL fusion transcript coding for the 210kDa BCR-ABL protein

 

Sprycel: 20 mg per day - taken at lights out with Quercetin and/or Magnesium Taurate

6-8 grams Curcumin C3 complex.

 

2015 PCR: < 0.01% (M.D. Anderson scale)

2016 PCR: < 0.01% (M.D. Anderson scale) 

March        2017 PCR:     0.01% (M.D. Anderson scale)

June          2017 PCR:     "undetected"

September 2017 PCR:     "undetected"


#9 Tedsey

Tedsey

    Advanced Member

  • Members
  • PipPipPip
  • 85 posts

Posted 23 April 2012 - 12:43 PM

Maybe after 2 1/2 years post dx, I am of the "old school".  I had severe cytopenia (low blood cells) of all types when I first began treatment.  I had low WBC, RBC, PLT, ANC, you name it.  I had drug interruptions the first few months.  After the onc at the time emailed Dr Druker, (specialist in Oregon), it was suggested that I not be taken off the TKI at all.  So, I weathered the storm with WBC stim shots and very painful RBC stim shots.  It helped a little, but not much.  My counts were as low as Michael's and Melanie.  It wasn't after I switched drugs that things got a bit better, but it took a long time.  It hasn't been until the last two CBCs I am anywhere close to normal with most of my counts.  PLT still remain very low.  However, no one will consider a dose reduction in my case.  I have done OK on the drugs, but am a slow responder (on full therapeutic dose).  Perhaps that is why.  You could always weather the storm, like I do.  Luckily, when my WBC were dangerously low, I never contacted any bugs I couldn't fight off.  Guess I have been lucky.  Now my issue is to try and not to bleed.  Hope they figure out soon what the dose reductions are all about.  Wishing you all good health.

Teds  



#10 Melanie

Melanie

    Advanced Member

  • Members
  • PipPipPip
  • 219 posts
  • LocationArizona

Posted 23 April 2012 - 06:13 PM

Thanks to everyone for their response and sharing. Trey, I appreciate the write up on CML genetics and have a clearer understanding. I have a question, although I think I know the answer from your article. Since the CML stem cell creates leukemic white cells and doesn't listen to the shut off call from the normal stem cell, does that mean that the neutrophils, esonophils, and basophils that do show up could be leukemic and not working at their best? 

It's always been my thought that staying on a lower dose is better than having to keep stopping and that maybe I'm just one of the slow responders too. My onc keeps trying to get me to "normal" dosage, thinking that's the only effective way to go. At my last BMB in Jan, he didn't even do a fish or PCR test, just checked for positive BCR/ABL. I asked him to at least do a FISH test on my blood this last month and his response was that the results would just depress me. I would like to see if there has been any positive response on the lower dosage, even if it's small. I'm getting neupogen shots to try and balance the ANC with the increase of my dosage of Tasigna to 450mg. Not an easy balance. How long were any of you kept at the lower dose before trying to increase? I'm more than willing to tough it out. If the neutrophils can be leukemic, are the shots a good idea? I haven't gotten sick either from the low ANC, but I'm fortunate that I have the ability to go into what I call my "bubble" when that happens.

Blessings to all...Melanie


Dx - 05/2011; PCR: 15.04; Fish: 87% Slow responder due to pancytopenia. Current - Bosulif - Nov: 2012, Mar 2016 lowered to 300 mg. 07/16 back to 400 mg. Clinical trial drug, Promacta, Feb 2013, for low Platelets.
CyCR - Aug 2014, Positive for 1 chromosome Sep 2015. PCR: 12.77 in Oct, 2012 to 0.04 (MDA) in Mar, 2016. 4/2016 - 0.126 (Local lab (IS); 05/2016 - 0.195 (local); 6/2016 - 0.07 (MDA); 7/2016 - 0.03 (local) 9/13/2016 - 0.16 (MDA); 9/26/2016 - 0.31 (MDA); 11/2016 - 0.012 (local); 01/2017 - 0.24 (MDA); 04/2017 - 0.09 (MDA); Cytogenetics show der(1:7)(q10;p10)7 chromosome mutation. Repeat of Sep 2015. PCR - 6/2017- 0.035 (local); 10/2017- 0.02 (MDA)

#11 pammartin

pammartin

    Advanced Member

  • Members
  • PipPipPip
  • 631 posts
  • LocationPennsylvania

Posted 23 April 2012 - 06:27 PM

I am wondering how much data is currently being documented on starting patients on a lower dose if they are in chronic phase of CML and then discussing increases of the dose if needed.  I have read so many stories where people are hit hard with the meds and then bottom out on labs, much like I did, wouldn't it be better to turn the trend around and add as needed instead of subtracting after the fact?  Is it because the CML needs to be hit hard initially or because this has been the standard treatment from the beginning.  I guess the other option would be a cross between the two.  This subject peaks my curiosity almost constantly and when I read of another person who takes the TKI, then has to stop for a length of time until the labs recover, wouldn't it be better to reverse the trend and see if that words just as well?   I realize I was hit hard but that was because I was diagnosed in accelerated stage, but most of the cases I read about are chronic.  Although I still believe if I were given the 140 mg of Sprycel and then monitored or kept on the 100 mg of Sprycel and then added the Hydrea I would have not bottomed out nearly as badly as I did.

Curiosity is one of my many vices.



#12 Lori's okay

Lori's okay

    Member

  • Members
  • PipPip
  • 21 posts
  • LocationWashington DC area

Posted 23 April 2012 - 07:05 PM

Isn't it great that they sell REALLY big hats in Texas?


DX 09-2011 PCR 8.08 not IS WBC 17 , Began Tasigna 600mg  

in 2012 Tasigna 450mg/day ,in 2013-2017 Tasigna 300mg/day

DATE/PCR

09-11/ 8.08 not IS

03-12/ 0.054 not IS

06-12/ 0.035 not IS

09-12/ PCRU, 01-13/ PCRU

4-13/ 0.042 IS

7-13/ 0.014 IS

11-13/ PCRU, 04-14/ PCRU

8-14/ 0.006 IS

PCRU: 12-14/ 05-15/ 10-15/ 02-16/ 

09-16/ 02-17/ 09-17/ 

10-17 tapered off 

11-3-17 Stopped Tasigna

1-15-18 still PCRU

 


#13 Trey

Trey

    Advanced Member

  • PS Beta Group
  • PipPipPip
  • 1,705 posts
  • LocationSan Antonio, Texas

Posted 23 April 2012 - 07:06 PM

Over time the good blood cells, with the help of the TKI drugs, get back in control as the leukemic cells are held in check by the drugs.  Even so, in Chronic Phase CML the leukemic cells still perform well.  It is only the advanced stages where the leukemic cells cease to work well enough, and the immune system breaks down.  I would not worry about these issues too much.  What you need is as we have discussed, which is to stay on as high a dosage of a TKI drug as you can and the rest will work out.



#14 Trey

Trey

    Advanced Member

  • PS Beta Group
  • PipPipPip
  • 1,705 posts
  • LocationSan Antonio, Texas

Posted 23 April 2012 - 07:16 PM

Big hats  are important in Texas.  In London, people wear little bitty hats with a large feather -- and call it macaroni. 

Phil and I have a  history around that "bigger hat" thingy.

http://community.lls...2&numResults=15



#15 pamsouth

pamsouth

    Member

  • Members
  • PipPip
  • 10 posts

Posted 23 April 2012 - 09:18 PM

PamMartin,

I say Amen to that  "on a lower dose if they are in chronic phase of CML and then discussing increases of the dose if needed."

I will never ever let them taken me down to low counts again!! To me that is just plain crazy, at least in my case. You know how you are scared out of your wits when diagnosed & know very little about the disease or the drugs or how you will respond you depend totally on the doctors.  I would never let my immune be comprised like that again. Quote Trey " Even so, in Chronic Phase CML the leukemic cells still perform well," yes they are mature, the cml cells still function, as long as they are not blast or acute.  I think for those who take low doses and are still within the guidelines, they are lucky, & it is easy for them to suggest otherwise, as to stick to guideline, because that is the safe requirement and that is a standard guideline world wide.  But for those who are on stronger doses of TKI's and they suffer ill side effects and quality life, that is another story.

Especially as you get older.  We took care of my mom for 3 years and I learned you should only give the elderly child like doses.  It is sad in the nursing home, they are so over drugged.  When your natural immune system or what you got left to fight with, is so compromised,  you are open to all kind of not only viruses but when things start to go wrong, well there is a lot of adjusting with other pills and things.  Not only that but I think sometimes when your organs start to take a hit, how much damage is irreversible.  Now if it was blast or acute that is another story, but not chronic.  Personally I think it can be just as bad to be over drugged as it is to have the cancer.  I mean even at undetectable you still have a lot of leukemia cells and you can live them.  No body know the long term outcome if which way you will live longer.  I think the less med's and chemicals, so your body has some fight of its own the better. I guess in my thinking which is going to get you first the cancer or the multiple drugs/chemical.  I asked a cardiologist last year how do you or any doctor know how all them drugs and chemical work together, he said you don't no one does. Having said all that, everyone is different and what might work for one person might not for another. 

My grip is, I think the medical professional should not push so hard to take a high dose, I don't think everyone fits into guideline set for the whole population.  As long as I am stable, and not going up,  I could care less if I was undetectable. Being undetectable makes people think they are cured and they when their counts change a smidget they get bent out of shape/stress.  I think there is also something to be said about quality of life.  I am sure there are other who will disagree but I still think it would be better if doctors didn't push so hard for a high dose.  I think most of it is research and theory.  I was reading an article, I don't remember the name of it, but I think it was in Japan.  400 mg gleevec was to much and 200 mg not enough and the general population was on the 300 mg, but then again you have some taking 200mg and undedectible.  Sorry wish I had written down the link.  There are lots of studies and research all over the world, and I imagine you can get a lot of different theories, however I think the majority will go with the standard guidelines. I think money play a huge factor. So I think a lot of it, do your own research and go with your gut, otherwise just do everything your doctor says. Personally  I don't think you can always go blindly by what a doctor says, they are not taking the drugs nor do they live with CML & the drugs, but then it is complicated so that is what we often do or are pushed to do.  Aur choices can get very limited. Because if the doctor doesn't agree with your decision then you will have to find another doctor so you can get your med's and labs.

Well that is my dollars worth.

PamSouth


PamSouth


#16 pammartin

pammartin

    Advanced Member

  • Members
  • PipPipPip
  • 631 posts
  • LocationPennsylvania

Posted 23 April 2012 - 09:32 PM

I need to understand this entire process in more detail.  It has been stated many times most people do not get to totally PCRU or MMR, but they are holding at a low level and doing well.  Is there a lower level that is acceptable, or is each doctor/hospital go by their own standards.  I guess I need to re-read some of Trey's info, but I am wondering how things are progressing with the new information and even if a person never reaches total response, what is the acceptable percentage before meds are changed, and things start becoming intense again.  Is this only when MMR or PCRU is lost or just because someone is holding at 11% for years. 



#17 Melanie

Melanie

    Advanced Member

  • Members
  • PipPipPip
  • 219 posts
  • LocationArizona

Posted 24 April 2012 - 02:21 PM

You all are the best...hats and all! Just got my labs in for this week and WBC is up to 4.4, PLT down to 64, ANC up to 1.9, and Bands up to 11. Best results since beginning of Feb, even though they come after 6 daily shots of Neupogen. See Onc tomorrow, hoping he'll leave me at 450 mg of Tasigna and not want to raise me to 600. Been at 450 for 3 weeks now and would like to stay for a while and try to slow down the shots. Been able to have some level of either Spycel or Tasigna consistant now for over 60 days which is the longest I've ever been on a drug since dx, last May 2011. Is it too early to ask for a Fish test? My last one was in Aug (69%), dx (87%). Any suggestions on dosage...stay at 450 or try to move up to 600? And what about all those Neupogen shots...how long can a person keep those up? I've had 35 since the end of Feb and we don't even want to talk about the cost...:) 

Thanks to all for commenting!  Blessings, Melanie


Dx - 05/2011; PCR: 15.04; Fish: 87% Slow responder due to pancytopenia. Current - Bosulif - Nov: 2012, Mar 2016 lowered to 300 mg. 07/16 back to 400 mg. Clinical trial drug, Promacta, Feb 2013, for low Platelets.
CyCR - Aug 2014, Positive for 1 chromosome Sep 2015. PCR: 12.77 in Oct, 2012 to 0.04 (MDA) in Mar, 2016. 4/2016 - 0.126 (Local lab (IS); 05/2016 - 0.195 (local); 6/2016 - 0.07 (MDA); 7/2016 - 0.03 (local) 9/13/2016 - 0.16 (MDA); 9/26/2016 - 0.31 (MDA); 11/2016 - 0.012 (local); 01/2017 - 0.24 (MDA); 04/2017 - 0.09 (MDA); Cytogenetics show der(1:7)(q10;p10)7 chromosome mutation. Repeat of Sep 2015. PCR - 6/2017- 0.035 (local); 10/2017- 0.02 (MDA)

#18 PhilB

PhilB

    Advanced Member

  • Members
  • PipPipPip
  • 130 posts

Posted 25 April 2012 - 06:06 AM

Hi Pam,

I am not aware that there are any formal guidelines on if / when to switch drugs to get a better response if you already have one which would be regarded as okay in Glivec-only days, but in terms of what the different response levels mean for likelihood of progreesion the basic rules are:?

  • The?re may be no such thing as 'total' response.  Even someone PCRU likely has millions of Ph+ cells.  PCRU just means below the limit of detection.  Only a small minority ever got there on G, although that's looking like a bigger minority on the newer drugs
  • The majority of people do get to MMR (3 log ie one thousand fold reduction).  There is no difference in outlook between MMR and PCRU.  In both cases the chance of the disease progressing is tiny
  • If you get to CCyR and maintain that level for 2 years then that is just as good as getting to MMR in terms of likelihood of progression

I would add that there is a small, but significant, bunch of people out there who have been plugging away for year?s without ever managing to attain a CCyR.  It isn't as 'safe' a place to be statistically as having a deeper response, but nor is it a guarantee of a bad outcome - smoking kills but there are plenty of 90-year-old smokers out there.



#19 PhilB

PhilB

    Advanced Member

  • Members
  • PipPipPip
  • 130 posts

Posted 25 April 2012 - 06:48 AM

Hi Melanie,

Glad to hear that your counts are looking better, but my sympathies on the Neupogen.  There are several on here who know far more about that stuff than they would ever have wished to.  A FISH test either now or soon sounds like a very good idea.  The name of the game is to get a dose level you can tolerate, but which is enough to control the CML.  Without the test you don't know anyhting about the second part of the equation so it's hard to speculate about what dose you 'should' be on.  If the T is doing the business at the current level then it wouldn't make much sense to increase the dose given the problems you're having.  If it is doing a great job then it may even be possible to go lower in search of better tolerance.  If, on the other hand, the current dose is struggling to make headway then it's back to head scratching time.    The debate between high dose plus stim shots vs low dose or dose interruption is one of the longest running and most lively in the business.

Fingers crossed that you have a great response and they can find a tolerable regime to maintain it.

Phil



#20 scuba

scuba

    Advanced Member

  • Members
  • PipPipPip
  • 1,044 posts
  • LocationHouston, Texas

Posted 25 April 2012 - 06:50 AM

Melanie,

I had severe myelosuppression - ANC < 0.2 after two weeks taking 70mg. Sprycel. My primary Oncologist wanted to shoot me up with Neupogen and keep me at 70mg. Dr. Cortes told me to stop taking the drug and no Neupogen. He told me, "CML is a slow disease. You have no blasts and your counts are dangerously low. Your blood will recover faster than CML will progress, we'll give it time". It took three months for my counts to recover and then only ANC = 1.0. At that level, I was restarted on Sprycel at 20mg. My ANC dropped again, but this time to 0.5 and stayed there for weeks. Dr. Cortes told me that as long as my ANC was above 0.5 he was o.k. with leaving me on the drug. After 7 months at 20mg. I was MMR. First my bone marrow went clear of any CML cells they could detect (cytogenetics = 0) and then my PCR kept dropping a log at a time.  My ANC is still around 1.6 or so (as measured in Februrary).

Dr. Cortes believes in using drug interruption and dose modification to treat his patients. He has had great success doing this. He told me there is some evidence (although I could not find any) that Neupogen stimulates the cancer cell production.


Diagnosed 11 May 2011 (100% FiSH, 155% PCR)

with b2a2 BCR-ABL fusion transcript coding for the 210kDa BCR-ABL protein

 

Sprycel: 20 mg per day - taken at lights out with Quercetin and/or Magnesium Taurate

6-8 grams Curcumin C3 complex.

 

2015 PCR: < 0.01% (M.D. Anderson scale)

2016 PCR: < 0.01% (M.D. Anderson scale) 

March        2017 PCR:     0.01% (M.D. Anderson scale)

June          2017 PCR:     "undetected"

September 2017 PCR:     "undetected"





1 user(s) are reading this topic

0 members, 1 guests, 0 anonymous users